Back at work and baby refuses to nurse at all

Hi I went back to work at 3.5 months and am at 4.5 months now. At 2 months we had some nursing challenges but we were able to get baby back to the breast eventually - with a LOT of great advice from this forum- and she would nurse at most scheduled times.

However, once I started back at work she was getting pumped BM (and one formula feeding a day) and over time started refusing to nurse even when I was home (2x a week plus weekends) - would arch her back and refuse to lie in any position to nurse. Middle of the night nursing is still good and she will sometimes nurse for a bit when I am putting her to sleep when she is asleep or when she wakes up in the morning. For the latter, if some one else picks her up or too much time has gone by since she work up, she will again refuse to nurse. She will babble and smile and want to play, but will not want the breast and will cry if I lie her down on my lap (or elsewhere) .

I finally decided last week to stop trying to nurse during the day when we are together (she is still being cared for by her nanny on weekdays; I am just working at home) and decided to increase my 3x a day pumping sessions in number. I did 2-3 days of 5x pumping but have now found my nipples are super painful (I had also upped the pumping intensity in a bid to get more milk faster) and sore ALL the time, to the point where I dread pumping. At the same time, I know that having her not nurse (other than the middle of the night) is probably already impacting my supply.
She drinks about 4 bottles of 4 oz during the day before I come home for her evening feed and I am definitely not producing enough to keep up. I have now switched to 2 formula feedings a day to avoid depleting my entire stash as we deal with the transition.

My questions are

a) What else can I do to help my nipples deal with the additional pumping and intensity? The pain is quite extreme. I have the Medela pump in style which has worked well for me; I bought a second pump a couple of weeks back and used that last week. I have been applying the APNO of late and also massaging some BM droplets back on them after pumping. Plus trying to air dry; though this is a pain at work.

b) How can I keep supply up at least such that I can provide 14-16 oz a day for her feedings other than the 1 of formula that I want to keep up? I take fenugreek three times a day. With the nipple soreness, I have switched back to pumping 4x a day starting today, and I know that while I am not getting enough milk at each set, that should improve over 1-2 weeks with regular and timely pumping. I also think she drinks more from the bottle than the breast.

c) She is sleeping longer during the night and my pedi thinks she can go the whole night without a feed soon. So, while I value the fact that her middle of the night feed helps build supply for me, I am reluctant to feed her in her sleep (unless she wakes up) because I certainly dont want to create a dependency of needing milk and me at night when she is ready to transition out. She sleeps around 7-7.30 and went back to getting up twice for a few nights just after I started work but now is back to once on most nights, somewhere between 2-4 am and then is up between 6-7 am. I know BF experts believe BF babies cant go for much more than 1 6 hr stretch without feeding but I think she may be an outlier as she started doing this very early in the day. I also have very busy work days and would love to be able to sleep more at night - I tried pumping a couple of nights but found that too exhausting.

d) I dont believe that I can bring her back to nursing without a significant investment in letting her not get a bottle, be hungry, cry etc (I have read many of the forum suggestions on this subject here). Do you have any advice on efficient ways to try and keep this alive, in case this is just a phase (though I dont think it is - she is now super aware of things and totally associates milk with the bottle). We have been using slow-flow pre newborn nipples on Dr brown bottles till now but have just bought the newborn ones.

While I am sad she doesnt associate nursing with me anymore, I believe it will be difficult for me to invest a lot of time (and more angst) in addressing this. The reality is that she spends most of her awake time during the week with the nanny and sees me for a couple of hours each evening. As my workload increases and I start traveling, this will remain the norm. My goal had been to BF till 6 mo to a large extent, which I guess I can still achieve with the pumping.

Re: Back at work and baby refuses to nurse at all

Exclusive pumping is HARD work. I have been doing it for 14+ months. So I think anything you can do to get her back to the breast is a GOOD thing. I would probably switch bottles myself to an alternative bottle like the Mumujumi or Breastflow or quit using a bottle entirely with a baby with nipple preference.

Besides, what you are talking about, unless she will nurse in the evenings and at night, is NOT enough to sustain your supply. At 3 months, an EPing mother should be pumping at least 6 times a day for a total of 120 minutes a day. I pumped 6 times a day from 3 months to just about 11 months. At that point, I dropped to four times day, but that wasn't quite enough to really sustain my supply.

EPing will also mean you probably need two things:
A different pump. I was horribly sore, just like you describe, until I quit using a professional grade pump at all and just a hospital grade pump, and quite honestly, once I switched to the Limerick, I got a bit sore again. The Symphony pump was the best for me for preventing soreness.
To be sized for horns. Yours may be too small, even if they look right.
Pumping TOO LONG and infrequently can lead to soreness. I was caught between a rock and a hard place as I don't let down well to a pump at all, and sometimes, it can take 5-10 minutes to get anything out, but if I pumped for 15 minutes as recommended, I was not empty
The suction can cause soreness. Turn it down.

Returning to the breast is hard work, but MUCH easier in the long run than EPing. EPing will always involve a lot of time, both at the pump, 120 minutes every 24 hours, plus washing up, and the loss of your special relationship with your baby, versus maybe a weekend or a week of some crying and fussing on your baby's part. I tried very, very hard. I succeeded with one baby to overcome nipple preference, but I was unsuccessful with my cleft baby. By the time he was physically able to nurse, he didn't know what to do.

Re: Back at work and baby refuses to nurse at all

It sounds like you are very concerend that you cannot invest the time and effort needed to encourage your child to nurse at the breast again or to maintain an appropriate supply in order to feed your child exclusively breast milk. If you decide you cannot do those things, and that is what works best for your life, then, that is your choice. In that case I suggest you own that choice and be happy with it. Your baby has had the irreplaceable benefit of your breastmilk & nursing at the breast for many months, and of course you can continue to combo feed as long as you have any breastmilk should you choose. Every drop of breastmilk and every minute at the breast has benefits. Are there more benefits from a health and overall wellness standpoint to baby getting most of their nutrition from breast milk for at least a year and nursing at the breast as much as possible? Of course. But if that is not going to work for you, it's not going to work. This a personal parenting choice.

If you decide you would like to keep trying to nurse at the breast, there are many things you can do to GENTLY encourage a child to nurse at the breast, starving a baby into nursing is not generally recommended so I am sorry if that is a recommendation you got here. The best article on back to the breast is this one: http://kellymom.com/bf/concerns/child/back-to-breast/ Also you could consider a lactation aid for when you are with baby.
Also is your nanny giving bottles in a breastfeeding supportive way? http://www.llli.org/docs/00000000000...astfedbaby.pdf

As you clearly know, the best way to keep milk supply appropriate (and baby happy and gaining) is to nurse frequently, and when baby cannot/will not nurse, to pump frequently. Additionally, you can try galactagogues, there are foods, herbs, and meds that help some moms increase milk supply. But frequent, effective milk removal from the breasts is number one for maintaining milk supply. See kellymom for great low supply info also lowmilksupply.org and the book Making More Milk.

pp has good input about pumps & pumping. Pumping should not hurt! Are you sure your pump is in perfect working condition, flanges the right size (breast size changes sometimes) or are you maybe pumping on too high a setting?

c) She is sleeping longer during the night and my pedi thinks she can go the whole night without a feed soon. So, while I value the fact that her middle of the night feed helps build supply for me, I am reluctant to feed her in her sleep (unless she wakes up) because I certainly don’t want to create a dependency of needing milk and me at night when she is ready to transition out. She sleeps around 7-7.30 and went back to getting up twice for a few nights just after I started work but now is back to once on most nights, somewhere between 2-4 am and then is up between 6-7 am. I know BF experts believe BF babies cant go for much more than 1 6 hr stretch without feeding but I think she may be an outlier as she started doing this very early in the day. I also have very busy work days and would love to be able to sleep more at night - I tried pumping a couple of nights but found that too exhausting.

Sleeping “through the night” is defined by the American Academy of Pediatrics as a single 5 hour stretch. Regular very long sleep stretches have been linked to slow weight gain as well as possibly lowering milk supply. But that does not mean, at all, that no baby can safely sleep longer. It is very individual. More on that in a bit.

By meeting a child’s nighttime need to nurse and comfort at the breast, a mother is not "creating" a dependency of needing milk or mom. A baby has those needs, naturally, and is not going to be developmentally ready to transition out of them at this age. Does that mean a baby won't sleep longer? No, some will, and it can sometimes impact mom’s supply, sometimes not, depending on why a baby is sleeping so long. Some babies sleep longer due to tanking up on bottles, or not sleeping in close proximity to mom. That can sometimes be a problem, milk supply wise. But sometimes, a baby who nurses frequently on cue all day, and sleeps in close proximity to mom will also sleep longer stretches. And in that case, the long sleep stretch will not likely cause any problems. But if mom is separated from baby most days, a long sleep stretch is possibly an issue. Here is why:

Breastfeeding is the biologically normal way to feed and comfort a baby. So everything about it works together, biologically speaking. If circumstances cause a change in one aspect of it, it may change things elsewhere. OK, so, mothers and babies being together, basically all the time, and nursing frequently, is the biological norm. (Biology does not make allowances for the existence of breast pumps, formula, or bottles or a mom needing to work outside the home. As far as biology is concerned, there is one way for a baby to survive and that means mom and baby being together all the time for both food and safety.)

From a biological standpoint, mothers do not nurse at night or nurse frequently other times in order to maintain milk supply, they nurse that way because that is what a baby needs. So by meeting a baby’s need to nurse frequently and for mother’s nearly constant presence (safety,) milk supply is kept appropriate, by biological design. When a breastfeeding mom goes back to work, she attempts to mimic the closeness of a nursing baby by pumping, which then (hopefully) provides her with appropriate supply going forward and milk for her baby when there is a separation. But often it is not enough, for many reasons, and night nursing becomes more vital for milk supply in those cases.

So, if a mother is separated from baby regularly, even if she is pumping at work, she is often going to need baby to nurse more when she is with baby (even at night) in order to maintain supply (and also, often, for baby to get enough milk overall.) So a mom who is separated from baby during the days is often going to need nighttime nursing sessions more than a mom who is able to nurse frequently all day. Working moms also often find that taking “nursing vacations’ on their days off helps maintain an appropriate supply.

Re: Back at work and baby refuses to nurse at all

Thank you to all three of you for all the excellent information and suggestions! Quick thoughts

a. I did get bigger shields/ flanges at the outset as the standard ones were too small for me. I dont think thats the issue now.

b. I pumped at lower suction of longer today and that helped the nipple soreness significantly.

c. Will explore the pump issue Susan mentions.

d. On getting baby back to the breast, I have tried many of the gentler approaches mentioned both here and at Kellymom and have not been successful. I had another round of nursing challenges a couple of months back and was able to successfully get her back to nursing then. As Meg reads well, I am not so sure I can do this at this stage. Instead, after reading everything I think that my best bet will be to nurse in the evening and night as much as possible, and keep up frequent pumping for the rest of the day - this evening, I reduced the amount of pumped BM my baby got before sleeping and (I believe) as a result, she nursed for a long time while she was falling asleep. Let's see how much milk I can manage this way over the next 1-2 weeks.

e. On the issue of sleeping through the night, Meg, your inputs are invaluable. Its good to be reassured that I can just follow my baby's lead on feeding (or not) and tust I will not be spoiling things in terms of keeping nighttime feedings unnecessarily alive for her.

And I will keep trying some of the other ways to coax her back to the breast but I am not expecting a lot of results - if I spent most of the time with her I think I could make a switch happen but with my current commitments outside the home, I doubt this can work.